CurrentevicorePolicy CMM-208

Ablations/Denervations of Facet Joints and Peripheral Nerves

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Defines medical necessity, procedural limits, imaging and guidance requirements, and indications for radiofrequency denervation/ablation of facet joints and select peripheral nerve destruction for Cigna-administered plans.

Policy Summary

Payerevicore

PolicyAblations/Denervations of Facet Joints and Peripheral Nerves

Policy CodePolicy CMM-208

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

Key ActionObtain and document two sequential diagnostic facet joint injections/medial branch nerve blocks demonstrating ≥80% relief and at least four weeks of conservative therapy within the prior three months (or document contraindication) before initial radiofrequency denervation/ablation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥80%diagnostic block relief

3 monthsmin pain duration

4 wksconservative tx

6 monthsinterval btwn RFAs

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CurrentevicorePolicy CMM-208

Ablations/Denervations of Facet Joints and Peripheral Nerves

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Policy Summary

Payerevicore

PolicyAblations/Denervations of Facet Joints and Peripheral Nerves

Policy CodePolicy CMM-208

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥80%diagnostic block relief

3 monthsmin pain duration

4 wksconservative tx

6 monthsinterval btwn RFAs

50% ≥12wksprior relief for repeat

Coverage Criteria for Facet Joint and Peripheral Nerve Denervation/Ablation

Initial Facet Joint Radiofrequency Denervation/Ablation

A facet joint radiofrequency denervation/ablation is considered medically necessary when ALL of the following are met:

Initial RFA criteria: Performed for facet-mediated cervical, thoracic, or lumbar axial pain resulting from disease, injury, or surgery; pain has persisted for at least three (3) months; in the past three (3) months pain has persisted despite at least four (4) weeks of conservative treatment (e.g., exercise, physical therapy, chiropractic care, or medications including NSAIDs or analgesics) unless contraindicated (if contraindicated, reason(s) must be documented); documented positive response with two (2) sequential diagnostic facet joint injections/medial branch nerve blocks at the same level(s) with at least 80% relief for at least the expected minimum duration of the effect of the local anesthetic used; clinical findings and imaging studies suggest no other obvious cause of the axial pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy; foraminal stenosis or disc herniation with concordant radicular pain that has been treated; infection; tumor; fracture; pseudoarthrosis; pain related to spinal instrumentation); the spinal motion segment(s) is(are) not posteriorly fused at the requested level(s) (exception allowed for clinically suspected pseudoarthrosis); for individuals with prior spinal fusion, RFA performed at an unfused spinal level contiguous with the fused segment is allowed when the above criteria are met.

Initial Therapy

A facet joint radiofrequency denervation/ablation is considered medically necessary when ALL of the following criteria have been met:

Initial denervation criteria: Performed for facet-mediated cervical, thoracic, or lumbar axial pain resulting from disease, injury, or surgery; pain persisted for at least three (3) months; within the past three (3) months pain persisted despite at least four (4) weeks of conservative treatment (e.g., exercise, physical therapy, chiropractic care, or medications including NSAIDs or analgesics) unless contraindicated and documented; documented positive response with two (2) sequential diagnostic facet joint injections/medial branch nerve blocks at the same level(s) with >=80% relief for at least the expected duration of the local anesthetic; clinical findings and imaging exclude other obvious causes (examples: central spinal stenosis with neurogenic claudication/myelopathy; foraminal stenosis or disc herniation with concordant radicular pain that has been treated; infection; tumor; fracture; pseudoarthrosis; pain related to spinal instrumentation); spinal motion segment(s) not posteriorly fused at requested level(s) (exception for clinically suspected pseudoarthrosis); for individuals with prior spinal fusion, procedure at an unfused level contiguous with fused segment is allowed when above criteria are met.

Repeat Therapy

A repeat facet joint radiofrequency denervation/ablation is considered medically necessary when ALL of the following criteria have been met:

Repeat denervation criteria: Procedure is performed at least six (6) months after the prior denervation/ablation; there is documented pain relief of at least 50% which lasted for at least 12 weeks after the prior procedure; clinical findings and imaging studies suggest no other obvious cause of the cervical, thoracic, or lumbar axial pain (e.g., central spinal stenosis with neurogenic claudication/myelopathy; foraminal stenosis or disc herniation with concordant radicular pain that has been treated; infection; tumor; fracture; pseudoarthrosis; pain related to spinal instrumentation); note: when repeating at the same spinal level(s) as a prior successful procedure, further diagnostic facet joint injections/medial branch blocks at those level(s) are not necessary.

Requests for CPT codes listed in the Codes section that are used for indications or conditions not specifically addressed in this guideline are considered out of scope and may be denied. The guideline and its criteria apply to facet joint radiofrequency denervation/ablation for facet‑mediated cervical, thoracic, or lumbar axial pain and to peripheral nerve destruction only when used for conditions explicitly addressed in this policy; determinations of medical necessity are made on a case‑by‑case basis.

The following alternative techniques for facet joint denervation/ablation are considered not medically necessary when used for facet joint procedures: pulsed radiofrequency ablation, endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy, cryoablation/cryoneurolysis/cryodenervation, chemical ablation (e.g., alcohol, phenol, glycerol), laser ablation, and cooled radiofrequency ablation. Additionally, radiofrequency procedures directed at the basivertebral nerve and procedures targeting nerves innervating the sacroiliac joint are considered experimental, investigational, or unproven for vertebrogenic back pain and SIJ pain, respectively; for SIJ ablation, see the referenced SIJ policy (CMM‑203).

No other explicit exclusions are listed in the cited reference list portion of the document; however, procedures that do not meet the Definitions, General Guidelines, or Indications sections (including anatomic level, prior conservative care, diagnostic block response, imaging, and fusion‑level rules) are identified elsewhere in this policy as not medically necessary and may be denied.

Facet joint radiofrequency denervation/ablation is considered medically necessary only for procedures performed at anatomic levels from C2‑3 to L5‑S1 and only when performed at unfused posterior spinal segments. Frequency limits include no more than two procedures at the same level during a rolling 12‑month period with at least six months required between procedures; when criteria are met, up to three contiguous levels (or up to six if bilateral) may be treated per session.

Procedures that do not meet the required Definitions, General Guidelines, and Indications in this policy—including documentation of ≥3 months of pain, required conservative therapy (≥4 weeks within the prior 3 months unless contraindicated), imaging to exclude other causes, and two sequential diagnostic facet joint injections/medial branch blocks demonstrating ≥80% relief for the expected anesthetic duration—are considered not medically necessary and are not covered under this guideline.

Ablation or denervation procedures directed at the basivertebral nerve (intraosseous radiofrequency for vertebrogenic endplate pain) and procedures targeting nerves innervating the sacroiliac joint are treated as distinct procedures from medial branch/facet denervation. These basivertebral and SIJ procedures are considered experimental, investigational, or unproven in this policy and are not covered here; see the SIJ policy (CMM‑203) for sacroiliac joint‑specific guidance. The references section of the document includes randomized and other studies related to basivertebral nerve ablation and other literature supporting distinctions between these procedures.

(Reserved) Additional content and references appear in the document reference list; detailed citations and studies supporting the policy are included in the References / Evidence Cited section of the full guideline.

Coding and Procedural Codes

Codes referenced for coverage reviewmixed

affected codes

CPT codes listed in the Codes section of the guideline (document references Codes section for full list)

Codes mentioned in EIU/code tableCPT

64628	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral
+64629	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure)
64633	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), cervical or thoracic, single facet joint
+64634	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
64635	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), lumbar or sacral, single facet joint
+64636	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

No explicit code lists in this excerptmixed

No codes listed

Diagnostic block response threshold — required pain relief on diagnostic block

Required pain relief>= 80% reduction in facet-mediated pain on diagnostic block

Number of positive blocks requiredTwo (2) sequential diagnostic facet joint injections/medial branch nerve blocks at the same level(s)

Duration requirementRelief must last for at least the expected minimum duration of the local anesthetic used

Miscellaneous coding key/value placeholder

Example CPT codes referenced64633, +64634, 64635, +64636, 64628, +64629 (listed in codes table)

Code inclusion note

Provider Requirements, Documentation, and Authorization

Prior Authorization

Prior authorization required; frequency and level limits

Prior authorization is required; determinations are made on a case-by-case basis. Frequency limits: no more than two facet joint radiofrequency denervations/ablations at the same level(s) during a rolling 12-month period, and at least six months must elapse between procedures. Up to three contiguous levels per session (up to six if bilateral) are allowed per guidance.

Prior authorization determinations are made by medical directors/health care professionals on a case-by-case basis.
Maximum of 2 RFAs at the same level(s) during a rolling 12-month period.
Minimum interval of 6 months between RF denervations/ablations.
Up to 3 contiguous levels per session (up to 6 total if bilateral).

Note

Code listing does not guarantee prior authorization or coverage

Inclusion of a CPT code in the document's code tables does not itself indicate it is managed or requires prior authorization; check the member's applicable health plan for prior authorization and payment rules.

Key Definitions

Facet Joint Pain definition

DefinitionFacet joint (zygapophyseal) pain: axial cervical, thoracic, or lumbar pain attributed to the paired synovial facet joints (C2-3 to L5-S1) innervated by medial branch nerves

Typical clinical featuresLocal paraspinal tenderness; pain increased with hyperextension, rotation, and lateral bending; low back stiffness; absence of neurologic deficit and root tension signs

Excluded articulationsAtlanto-occipital and atlanto-axial articulations and levels below L5-S1 are not considered facet joints in this policy

Positive Response — >=80% relief definition for diagnostic facet/medial branch block

Threshold for positive response>= 80% relief of facet-mediated pain

Temporal requirementRelief must persist for at least the expected minimum duration of the local anesthetic used

Conservative Therapy Requirements Before Ablation

Required unless contraindicated — >= 4 weeks within past 3 months

Required unless contraindicated: at least four (4) weeks of conservative treatment within the prior three (3) months.

Conservative treatment requirement: At least four (4) weeks of conservative treatment (e.g., exercise, physical therapy, chiropractic care, or medications including NSAIDs or analgesics) within the past three (3) months prior to consideration of RFA; if conservative treatment is contraindicated, the reason(s) must be documented in the medical record.

Required prior to initial denervation unless documented contraindication — >=4 weeks within prior 3 months

Required prior to initial denervation unless documented contraindication:

Prior conservative therapy before initial RFA: Documentation of at least four (4) weeks of conservative therapy within the prior three (3) months (examples include exercise, physical therapy, chiropractic care, or medications including NSAIDs or analgesics). If conservative therapy is contraindicated, the contraindication must be documented.

Frequency and Interval Limits for Procedures

Facet joint radiofrequency denervation/ablation — frequency limits

Rolling 12-month limitNo more than two (2) facet joint RF denervations/ablations at the same level during a rolling 12‑month period

Minimum intervalAt least six (6) months is required between facet joint RF denervations/ablations

Levels per sessionUp to three (3) contiguous levels per session (up to six total if bilateral)

Repeat facet joint radiofrequency denervation/ablation — minimum 6 months between procedures

Minimum time between repeat proceduresMinimum of six (6) months between procedures

Documentation for repeatDocument date of prior denervation and prior relief (>=50% for >=12 weeks) when requesting repeat procedures

Imaging and Procedure Guidance Requirements

Billing Rule

Image guidance (CT or fluoroscopy) required for RFA

Facet joint radiofrequency denervation/ablation is considered medically necessary when performed with CT- or fluoroscopic-guidance once criteria are met; image guidance is required for covered RFA procedures.

CT or fluoroscopic guidance is required when criteria have been met for RFA.

Documentation Required

Use imaging to exclude alternative causes before initial and repeat RFA

Clinical findings and imaging must exclude other obvious causes of axial pain for both initial and repeat denervation/ablation; imaging is used to rule out conditions such as central stenosis, treated radicular disease, infection, tumor, fracture, pseudoarthrosis, or instrumentation-related pain.

Not Covered / Out-of-Scope Procedures and Techniques

Requests for CPT codes listed in the Codes section that are submitted for indications not addressed in this guideline are out of scope and may be denied; inclusion of a code in the document does not itself imply coverage for indications beyond those specifically described.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are considered not medically necessary for facet joint denervation/ablation and are not covered under this guideline.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are listed as not medically necessary techniques for facet joint denervation/ablation and therefore are not covered.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are not considered medically necessary for facet denervation and are not covered.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are designated not medically necessary and are excluded from coverage.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are not covered under the policy.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are considered not medically necessary and therefore not covered.

Background

Facet (zygapophyseal) joints are paired synovial joints that can generate axial cervical, thoracic, or lumbar pain. They are innervated by medial branch nerves; radiofrequency ablation (RFA) targets those medial branch nerves using a heated probe under image guidance to create a thermal lesion and denervate the facet joint. Prior to RFA, diagnostic medial branch blocks or facet joint injections are performed to identify facet‑mediated pain, with a positive response defined as at least 80% pain relief for at least the expected duration of the local anesthetic.

Policy Summary

Payerevicore

PolicyAblations/Denervations of Facet Joints and Peripheral Nerves

Policy CodePolicy CMM-208

Change TypeNo material changes

Effective DateAug 4, 2026

Next Review Date

SourceLink

On This Page

Inclusion in the document's code table does not itself imply management or prior authorization; check applicable health plan

Code systemCPT (as listed in the Codes section)

The code table states that inclusion of any code does not imply it is under management or requires prior authorization.
Refer to the applicable health plan (Certificate of Coverage/Evidence of Coverage) for management details and prior authorization requirements.

Note

Prior authorization statements — none additional in this section

No explicit prior authorization statements are present in the referenced portion of the document beyond general case-by-case determinations; use the applicable health plan and EviCore review processes for authorization requirements.

This portion of the document contains citations/references and does not add additional PA rules.
Follow the plan-specific prior authorization process for Cigna-administered benefits.

Step Therapy

Show failure of ≥4 weeks conservative therapy within prior 3 months

Documented failure of at least four (4) weeks of conservative treatment within the prior three (3) months is required before RFA unless conservative treatment is contraindicated and the contraindication is documented.

Conservative treatments examples include exercise, physical therapy, chiropractic care, or medications including NSAIDs or analgesics.
If conservative treatment is contraindicated, the reason(s) must be documented in the medical record.

Step Therapy

Conservative care (≥4 weeks) required before initial ablation unless contraindicated

Prior to initial facet joint denervation/ablation, providers must document at least four (4) weeks of conservative therapies within the preceding three (3) months (e.g., exercise, physical therapy, chiropractic care, or NSAIDs/analgesics), unless a documented contraindication exists.

Examples of acceptable conservative treatments: exercise, physical therapy, chiropractic care, NSAIDs or other analgesics.
Contraindications to conservative care must be explicitly documented.

Note

Miscellaneous provider actions

No additional miscellaneous provider actions are specified in the referenced excerpt; follow the criteria, documentation, and prior authorization rules elsewhere in the policy.

This section of the source contains references and does not add new provider action requirements.

Documentation Required

Required documentation: pain duration and conservative therapy details

Document duration of axial pain of at least three (3) months and either details of at least four (4) weeks of conservative therapy within the past three (3) months or documentation of why conservative treatment is contraindicated.

Record onset and duration of pain (≥3 months).
Specify conservative therapy type(s), duration (≥4 weeks within prior 3 months), and responses, or document contraindications to such therapy.

Documentation Required

Required clinical documentation: diagnostic block results, imaging, and conservative care

Include clinical specifics: duration of pain (≥3 months), prior conservative treatments and their durations, reason(s) if conservative care was contraindicated, results of two sequential diagnostic facet joint injections/medial branch blocks showing ≥80% relief for the expected anesthetic duration, and imaging/clinical findings excluding other causes.

Two sequential diagnostic facet joint injections/medial branch blocks with documented ≥80% relief for expected anesthetic duration.
Imaging and clinical documentation that exclude other obvious causes (e.g., central stenosis, treated radicular disease, infection, tumor, fracture, pseudoarthrosis, instrumentation-related pain).

Documentation Required

Documentation required for repeat procedures: prior date and ≥50% relief ≥12 weeks

For repeat denervation/ablation, document the date of the prior denervation, and that prior pain relief was at least 50% and lasted for at least 12 weeks; ensure the repeat procedure is performed at least six (6) months after the prior procedure.

Prior procedure date must be provided.
Documented prior relief ≥50% lasting ≥12 weeks is required to qualify for repeat RFA.
Repeat procedures must occur a minimum of 6 months after the prior denervation/ablation.

Note

Literature references — no additional provider actions

These chunks list literature references only and do not impose additional provider actions; use the policy's criteria and documentation requirements for clinical decision-making and authorization.

Referenced studies and guidelines are cited for evidence but do not add procedural requirements in this excerpt.

Denial Risk

Denial trigger: out-of-scope indications or missing required diagnostic/therapy documentation

Requests for CPT codes used for indications or conditions not addressed by this guideline are out of scope and may be denied; absence of documented positive responses to two sequential diagnostic facet joint injections/medial branch blocks (≥80% relief) or missing conservative therapy, duration, imaging, or fusion-level documentation may trigger denial.

Procedures for indications outside the guideline scope are subject to denial.
Lack of two sequential positive diagnostic blocks (≥80% relief) or missing required documentation may result in denial.

Denial Risk

Denial risk if Definitions, Guidelines, or Indications not met

Procedures performed without meeting the Definitions, General Guidelines, and Indications sections are considered not medically necessary and may be denied.

Failure to meet policy definitions/guidelines/indications constitutes insufficient medical necessity.

Denial Risk

Denial risk for non-covered techniques (pulsed, endoscopic, cryo, chemical, laser, cooled RF)

Use of pulsed RF, endoscopic RF/dorsal ramus rhizotomy, cryoablation/cryoneurolysis, chemical ablation (e.g., alcohol, phenol, glycerol), laser ablation, or cooled RF for facet joint denervation/ablation is considered not medically necessary and may be denied.

Listed techniques are explicitly identified as not medically necessary for facet joint denervation/ablation.

Note

Provider actions — no additional triggers in this section

No additional provider authorization or denial triggers are specified in this excerpt; adhere to the policy's stated criteria and plan-specific authorization processes.

This portion of the document contains references only and does not add new action items.

ApplicationUsed to document response to a diagnostic facet joint injection or medial branch nerve block prior to RFA

Facet Joint RFA definition — probe placement toward medial branch under fluoroscopy guidance

Procedure descriptionInsertion of a radiofrequency probe under fluoroscopic guidance directed toward the medial branch of the posterior primary rami to create a continuous heat lesion

TargetMedial branch nerves supplying the facet joint(s)

GuidanceFluoroscopic (image) guidance is required when criteria are met

Positive response to diagnostic facet joint injection/medial branch block — >=80% relief for expected duration of anesthetic

Positive response magnitude>= 80% relief of facet-mediated pain

Duration requirementRelief must last for at least the expected minimum duration of the local anesthetic used

UseEvidence of this response on diagnostic facet joint injection/medial branch block supports proceeding to RFA

Repeat facet joint denervation/ablation definition — criteria for repeat

Minimum interval for repeat procedureAt least six (6) months after the prior denervation/ablation

Prior response requiredDocumented prior pain relief of at least 50% that lasted for at least 12 weeks after the prior procedure

Diagnostic blocks for repeatWhen repeating at the same spinal levels as a prior successful procedure, additional diagnostic facet injections/medial branch blocks are not required

Basivertebral nerve ablation definition — targeted intraosseous RFA for vertebral endplate–related chronic low back pain

DefinitionBasivertebral nerve ablation: targeted intraosseous radiofrequency ablation directed at the basivertebral nerve to treat vertebral endplate–related chronic low back pain

Evidence noteSupported by randomized sham-controlled studies cited in the references (e.g., Fischgrund et al., Int J Spine Surg. 2019)

Coding referenceProcedure codes for basivertebral nerve thermal destruction appear in the codes table (e.g., 64628, +64629)

Medial branch radiofrequency neurotomy/denervation definition — RF lesioning of medial branch nerves supplying facet joints

DefinitionMedial branch radiofrequency neurotomy/denervation: radiofrequency lesioning of the medial branch nerves supplying the facet joints to denervate the joint and reduce facet-mediated spinal pain

TechniqueTraditional/standard RFA creates a continuous heat lesion via a radiofrequency electrode placed toward the medial branch under fluoroscopic guidance

IndicationUsed for facet-mediated axial cervical, thoracic, or lumbar pain in appropriately selected patients

Diagnostic blocks not required if prior successfulWhen repeating at same levels as a prior successful denervation, further diagnostic blocks at those levels are not necessary

Frequency limits placeholder

Max procedures at same levelNo more than two (2) RFAs at the same spinal level in any rolling 12‑month period

Minimum intervalAt least six (6) months between RF denervations/ablations

Session level limitsUp to three (3) contiguous levels per session; if bilateral, up to six (6) total procedures per session

Document imaging/clinical evaluation excluding alternative causes before initial or repeat RFA.
Examples of excluded causes are listed in the Indications section (central stenosis, foraminal stenosis/disc herniation with radicular pain, infection, tumor, fracture, pseudoarthrosis, instrumentation-related pain).

Note

Cited literature commonly uses image-guided RFA — document imaging modality

Many of the cited studies and guideline references describe procedures performed under fluoroscopic or CT guidance; when documenting clinical rationale, reference that published evidence often uses image-guided techniques for RFA.

Cited literature (e.g., randomized trials and reviews) frequently reports use of fluoroscopic or CT guidance for radiofrequency procedures.
Include imaging modality used when reporting the procedure to align with evidence and policy guidance.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are excluded from coverage as not medically necessary techniques.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are listed as not medically necessary and are not covered.

Pulsed radiofrequency ablation for facet joints and endoscopic radiofrequency denervation/endoscopic dorsal ramus rhizotomy are not covered per the policy.